BADAN EKSEKUTIF MAHASISWA

SEKOLAH TINGGI ILMU KESEHATAN BINAWAN

Jl Raya Kalibata No 25-30 Cawang Kramat Jati Jakarta Timur
DKI Jakarta 13540 Tlp 021 8088 0882

FORMULIR PENDAFTARAN PENCALONAN KETUA BADAN

EKSEKUTIF MAHASISWA STIKes BINAWAN

I. IDENTITAS DIRI
NAMA LENGKAP

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NAMA PANGGILAN

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TEMPAT TANGGAL LAHIR

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ALAMAT

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NOMOR TELEPON/HP

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PROGRAM STUDI

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ANGKATAN/SEMESTER

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NOMOR INDUK MAHASISWA :........................................................................................

EMAIL/FB/TWITTER

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HOBBY

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MOTTO HIDUP

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BADAN EKSEKUTIF MAHASISWA

SEKOLAH TINGGI ILMU KESEHATAN BINAWAN
Jl Raya Kalibata No 25-30 Cawang Kramat Jati Jakarta Timur
DKI Jakarta 13540 Tlp 021 8088 0882
PRESTASI

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II. PENGORGANISASIAN
RIWAYAT ORGANISASI

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2. ..................................................................................
3. ..................................................................................

UKM YANG DIIKUTI

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VISI

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MISI

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ALASAN PENCALONAN

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BADAN EKSEKUTIF MAHASISWA

SEKOLAH TINGGI ILMU KESEHATAN BINAWAN
Jl Raya Kalibata No 25-30 Cawang Kramat Jati Jakarta Timur
DKI Jakarta 13540 Tlp 021 8088 0882

Dengan ini saya menyatakan, pengisian formulir ini saya lakukan dengan penuh kesadaran
serta kebenaran yang dapat dipertanggung jawabkan.

Jakarta, .......................... 20....

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